1. Cascade of care for people who use drugs - opportunities for integration and scale up of harm reduction services and other evidence based interventions
Dr Martin van Den Boom, MD, MSc PH, Technical Officer, Joint TB, HIV and viral Hepatitis Programme, WHO Regional Office for Europe

2. Outline
Cascade of care for people who use drugs - opportunities for integration of harm reduction services and other evidence based interventions
Challenges in the cascade of care for people who use drugs
Evidence interventions not delivered to scale
Structural barriers
Comprehensive package of services for people who inject drugs
Impact of scale up and service integration
Hepatitis: impact of scale up and service integration
Service delivery strategies
Summary

3. Cascade of care for people who use drugs
At each point in the cascade we can introduce opportunities for integration of harm reduction services and other evidence based interventions
At point of diagnosis (testing) by integrating routine testing into a range of services for drug users including: drug treatment, needle syringe programmes (NSEP) and criminal justice settings; using mobile, self and peer testing and other decentralized (community) testing interventions and removing structural barriers (legal and regulatory barriers are hindering modernizing HIV testing across Europe). Rapid tests (approved by WHO and GF) are an important tool in increasing testing coverage.
At point of linkage to care careful case management, systematic monitoring of entry to treatment and intensive community outreach (including peer support and professional “navigators”) can reduce the number lost to (or delayed to entering) treatment.
At point of retention in care the use of OST (opioid substitution therapy) for opioid dependent patients is extremely effective in increasing and sustaining retention in care. Integration of HIV treatment (ART) and opioid substitution therapy (OST) can significantly increase retention and outcomes for people who people who use and inject opioids.
OST for opioid dependent patients on ART improves outcomes and adherence. All people who use drugs can benefit from better integration of drug dependency services and ART services.
Kamarulzaman A and Altice FL The Challenges in Managing HIV in People Who Use Drugs Current Opinion in Infectious Diseases 2015 Feb; 28(1): 10-16

4. Challenges in the cascade of care for people who use drugs % of people who inject drugs that have received an HIV test in the past 12 months and know their results (median values) (2015 data from 63 countries) Data from UNAIDS, 2016;
Challenges in the cascade of care for people who use drugs include the low proportion of drug injectors tested; here (slide) although the situation is marginally better than in other WHO Regions only 41% of people who inject drugs had received an HIV test in the past 12 months and knew their results

5. Challenges in the cascade of care for people who use drugs
Proportion of injection drug users living with HIV who receive antiretroviral therapy, by region
Another important challenge in the cascade of care for people who use drugs is the low proportion of drug injectors living with HIV receiving ART
Joanne Csete et alPublic health and international drug policy The Lancet  Volume 387, Issue 10026, Pages (April 2016)

6. Evidence interventions for drug users not being delivered at sufficient scale Number of needle syringes dispensed per PWID per year by country*
1 needle/syringe per day per PWID
UN recommendation (200 NS per yr per PWID)
Evidence that interventions for drug users are not being delivered at sufficient scale include the relatively few countries that meet the UN recommendation of 200 syringes per injector per year.
*Data from UNAIDS, 2015;

7. Evidence interventions for drug users are not being delivered at sufficient scale Median percent of people with opioid dependence receiving opioid substitution therapy, 2015
Source: 2016 Global AIDS Response Progress Reporting; UNODC. World Drug Report 2016.
Here we can see that while countries in western and central Europe and north America exceed the UN recommendation of at least 40% of people with opioid dependence receive opioid substitution therapy the countries of Eastern Europe and central Asia fall far short of that target.

8. Structural barriers influence HIV risk and service uptake for people who use drugs
Criminalisation of drug use
Punitive, restrictive policies
Stigma
Violence
Arrest
Incarceration
Reduced access to prevention, testing and treatment services
Structural barriers influence HIV risk and service uptake here we can see how criminalisation of drug use and punitive, restrictive policies: increase stigma and marginalisation; lead to violence, arrest and incarceration; which in turn reduces access to prevention testing and treatment services and an increased risk of HIV infection and poor health outcomes.
Other structural barriers include: age restrictions and affordability of services.
Increased risk of HIV infection
Poor health outcomes *

9. Removing structural barrier reduces HIV risk: example Portugal decriminalization of drug use
Removing a structural barrier – example Portugal decriminalization of drug use. Since the decriminalization of drug use in Portugal the overall number of new HIV cases among people who inject drugs has fallen as has the proportion of people who inject drugs among all new HIV cases.

10. A comprehensive package of interventions to prevent new infections in PWID1
Health sector interventions
Needle/syringe programmes
Opioid substitution therapy
Anti-retroviral therapy
HIV testing and counselling (community based testing is recommended by WHO)
Prevention and treatment of STIs
Condom provision
Targeted information, education and communication
Prevention, diagnosis treatment and vaccination against viral hepatitis
Prevention, diagnosis and treatment of tuberculosis
Provision of naloxone and training on overdose prevention for PWID community
Critical enablers
Supportive legislation and policy
Addressing stigma and discrimination
Community empowerment
Addressing violence against PWID
Accessible, available and acceptable services for PWID
Provided in combination, at high coverage levels, these 3 interventions can reduce up to 50% of new infections in PWID2
A comprehensive package of interventions to prevent new infections in PWID includes health sector interventions – most critically needle syringe programs, opioid substitution therapy and anti-retroviral therapy. If provided in combination, at high coverage levels, these 3 interventions can reduce up to 50% of new infections in PWID.
Critical enablers address the structural barriers that increase HIV risk and decrease service uptake for people who use drugs
1. WHO 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
2. Louisa Degenhardt et al Prevention of HIV infection for people who inject drugs: why individual,
structural, and combination approaches are needed Lancet 2010; 376: 285–301

11. Impact of scale up and service integration (ART + OST + NSP) on HIV modelled for three countries
Required scale-up of ART, NSPs, and OST to achieve 30% or 50% decrease in incidence or prevalence of HIV among people who inject drugs over 10 years in Tallinn, Estonia (A), St Petersburg, Russia (B), and Dushanbe, Tajikistan (C)
Impact of scale up and service integration (ART + OST + NSP) modelled for three countries
Joanne Csete et alPublic health and international drug policy The Lancet  Volume 387, Issue 10026, Pages (April 2016)

12. Global epidemiology of hepatitis and drug injecting
250 million people use illicit drugs/year*
General shift from opioids and injecting to stimulant use
12 million people inject drugs
158 countries report injecting drug use
96 countries report HBV and 108 HCV in PWID**
~6.4 million PWID with HBV (59 countries) ***
~10 million PWID with HCV (77 countries)
HCV prevalence in PWID >50% in most countries
between 60-80% in 25 countries >80% in 12 countries.
*UNODC, World Drug Report 2016 ;**Harm reduction International, 2016; *** Nelson et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet, 378 (9791), 2011.
Importance of drug injectors to global hepatitis epidemiology
Estimates suggest that 12 million people inject drugs – 6.4 million injectors have HBV and 10 million HCV
HCV prevalence in people who inject drugs >50% in most countries

13. cirrhosis and hepatocellular carcinoma
Global epidemiology of hepatitis and drug injecting Proportion of new infections, chronic infections and deaths from injection drug use for HBV and HCV, 2015
New infections
Chronic infections
Deaths from
cirrhosis and hepatocellular carcinoma
Total
Attributable to current injection drug use
Among persons who currently or recently inject drugs
Attributable to lifetime injection drug use
# (million) %
# (000s)
HBV
N/A
1.2%
196
0.9
0.5%
887.2
8,1
0.9%
HCV
1.7
0.39
23.0% 71
5.6
7.9%
339.4
126,0
31.5%
Importance of drug injectors to hepatitis epidemiology
23% of new HCV infections can be attributable to injection drug use
31.5% of deaths from cirrhosis and hepatocellular carcinoma can be attributable to injection drug use
People who inject drugs are a priority group for HCV prevention and treatment.
Based on P Nelson et al, 2011 and L Degenhardt et al, 2016

14. Hepatitis Prevention Guidance for People Who inject Drugs
Confirms need for scaling up harm reduction, and includes new recommendations:
Offer PWID the rapid hepatitis B vaccination regimen*
Offer PWID incentives to increase uptake and completion of the hepatitis B vaccine schedule†
Needle and syringe programs to also provide low dead-space syringes for distribution to PWID ‡
Psychosocial interventions are not suggested for PWID to reduce the incidence of viral hepatitis
Offer peer interventions to PWID to reduce the incidence of viral hepatitis.
WHO guidance for prevention of hepatitis in drug injectors includes:
Vaccination
Low dead-space syringes
Peer interventions
* A higher dose HBV vaccine should be used with the rapid regimen; standard and rapid regimens should be offered to PWID, with first priority given to delivery of the first dose and then to completion of three doses. † This recommendation is conditional on local acceptability and resource availability; vaccinations should be provided at a location and time convenient for PWID. ‡ Needle and syringe programmes should offer all types of syringes appropriate for local needs.

15. Impact of scale up and service integration (OST + NSP) on HCV modelled
Csete et al, Lancet 2016
This model demonstrates the potential impact of scale-up and integration of OST and NSP (at different levels of coverage) on HCV. However, only around half countries provide NSP and OST and complete data are lacking on the number of countries providing HCV treatment to drug injectors.
Joanne Csete et alPublic health and international drug policy The Lancet  Volume 387, Issue 10026, Pages (April 2016)

16. Service delivery strategies to increase access for PWID
Integration of services
ART +OST +NSP1
HIV Testing & Counselling (HTC) 2 +ART +OST +NSP
HTC +ART +OST +NSP +TB +Hepatitis (prevention, diagnosis & treatment)
above +
prevention and treatment of STIS
condom programmes
targeted information, education and communication
vaccination for hepatitis
Decentralisation of services – non medical facilities, outreach, community
Task-shifting – non medical specialists, NGOs, community based
Community-based approaches – lay and self-testing, treatment retention and adherence support
Services in prison – and other detention facilities
Service delivery strategies to increase access for PWID
Integration of services; Decentralisation of services; Task-shifting; Community-based approaches; Services in prisons
1 other drug dependence treatment for non opiate users and non-injectors and auxiliary equipment for hepatitis prevention 2 HTC including rapid testing

17. Summary
Cascade of care for people who use drugs presents opportunities for integration of harm reduction services and other evidence based interventions
Challenges in the cascade of care for people who use drugs include low proportion of drug injectors tested and receiving ART and other services
Comprehensive package of services for people who inject drugs and removal of structural barriers increase both service scale up and integration
Service scale up and integration impact HIV and Hepatitis decreasing prevalence and incidence
Service delivery strategies to increase access to services include integration and decentralisation of services

18. Thank you With acknowledgement to:
Virginia MacDonald HIV Department, WHO Geneva
Martin Donoghoe Joint Tuberculosis HIV and Hepatitis Programme Division of Health Emergencies and Communicable Diseases (DEC), WHO Regional Office for Europe